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NCP Proper No.

1 Ineffective airway clearance


ASSESSMENT
S> "Nahihirapan siyang huminga, lalo pagmadaming plema" as verbalized by wife. O>With tracheostomy tube connected to a t-piece. > On O2 inhalation of 2-3 liters per minute >RR:24-26 breaths per minutes >SPO2: 88% >Use of accessory muscles noted. > Crackles noted on both lung fields upon auscultation. >Secretions noted to be greenish to yellowish in color,

EXPLANATION OF THE PROBLEM


Inflammatory mechanism

OUTCOME CRITERIA
STO: After 2 hours of nursing and medical interventions patient will: a) Maintain a patent airway through suctioning. b) Maintain a normal respiratory rate of 12-20 breaths per minute. c) Maintain a normal level of SPO2. LTO: After 3 days of nursing and medical interventions: 1) Family will demontrate: a) Proper suctioning b) Log rolling to help in immobilizin g the

INTERVENTION
Dx>Assessed respirations: noted quality, rate, pattern depth, use of accessory muscles >Assessed airway patency through auscultation of lung fields. >Assessed changes in vital signs and SPO2.

RATIONALE
>Abnormality indicates respiratory compromise. To ascertain status and note progress > To monitor is condition is improving or worsening. > Changes such as increase in temperature, heart rate and respiratory rate may indicate increased work load in breathing or there is a presence of infection. > To determine if infection is present. A sign of infection is discolored sputum, and an odor may be present. >These promote better lung

EVALUATION
STO: Fully Met, as evidenced by patent airway, normal SPO2 and respiratory rate. LTO: Partially met due to patient refusing log rolling due to pain felt and the watchers sometimes do not log roll the patient

Increased activity of goblet cells

Increased mucus production

Inability to cough out phlegm

Retention of phlegm in the tracheobronchial walls

>Monitored change of sputum: amount, color and consistency.

Tx>Maintained on semi-fowlers position. >Maintained oxygen inhalation at 2-3

INEFFECTIVE

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amounting approximately 5ml, slightly viscous in consistency. > Restlessness noted. >With pale nail beds noted. > On semifowlers position. A>Ineffective airway clearance related to pooling secretions and inability to cough out phlegm.

AIRWAY CLEARANCE

phlegm from the lung walls. 2) Patient will demonstrate the following: a) Proper deep breathing and coughing exercises. b) Reduction of congestion with clear breath sounds.

liters per minute.

expansion. > Supplemental oxygen is provided to relieve/prevent dyspnea and to improve oxygencarbon dioxide exchange. >Suctioning is indicated when patients are unable to expectorate secretions from the airway by coughing because of weakness, thick mucus plug, or excessive mucus production. > Ambroxol helps in liquifying the secretions making expectoration or suctioning easier. >To aid in immobilizing the secretions from the lung walls for better expertoration or suctioning. >Promotes better lung expansion.

>Suctioning every hour and as needed.

>Facilitated nebulization of ambroxol 2.5ml + 2ml PNSS every 6 hours. >Facilitated log rolling and back tapping.

Ed> Encouraged deep-breathing and coughing exercises. >Encouraged increase fluid intake. >Encourage adequate rest periods and

>To reduces the

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minimizing visitors.

viscosity of secretions in the airway. > To prevent or lessen fatigue.

NCP Proper No. 2 Impaired gas exchange


ASSESSMENT EXPLANATION OF THE PROBLEM OUTCOME CRITERIA INTERVENTION RATIONALE EVALUATION

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O>On tracheostomy tube connected to a tpiece. >Use of accessory muscles noted. >Irregular breathing pattern noted. > Crackles and wheezes noted upon auscultation of both lung fields. > RR: 24-26 breaths per minute >O2 inhalation of 2-3 liters per minute. >Restlessness noted. A>Ineffective breathing pattern related to weakened respiratory muscles

Affected phrenic nerve that exit at the C3-C5

Impairment of the diaphragm function

Decrease respiratory muscle strength

STO>After 3 hours of nursing interventions the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern such as. a) Deep breathing exercises b) Coughing exercises LTO> After 3 days of nursing interventions, the patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.

Dx> Assessed breath sounds through auscultation of both lung fields. > Assessed rate and depth of respirations, type of breathing pattern.

> To identify the character of breath sounds and know which lobe is most affected. >To identify early warning signs of impending respiratory distress for immediate treatment. > These signify an increase in work of breathing. >Inadequate oxygenation causes increase pulse rate. SPO2 is useful in detecting changes in oxygenation. >Ambroxol helps liquify the secretions makinf expectoration or suctioning easier. > This is for good chest expansion. > This provides adequate oxygenation to

STO: Fully Met. As evidenced by the patient demonstrating the following: 1) Deep Breathing Exercise 2) Coughing Techniques

>Assessed use of accessory muscles in breathing. > Monitored vital signs and SPO2.

INEFFECTIVE BREATHING PATTERN

Tx>Facilitated 2.5cc Ambroxol + 2cc PNSS nebulization. >Positioned on semi-fowlers position. >Maintained on oxygen inhalation

LTO: Fully Met. The patient applied techniques that improved breathing pattern such as deep breathing exercises and is free from signs and symptoms of respiratory distress as evidenced by respiratory rate is withing normal range and absence of cyanosis.

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at 2-3 liters per minute per tpiece. >Provided scheduled for adequate rest periods and clustered nursing activities. Ed>Encouraged to do deep breathing exercises and coughing techniques. >Educated watchers on early signs and symptoms of respiratory distress such as restlessness and difficulty of breathing.

prevent patient from desaturation. >To conserve oxygen consumption, and to minimize interruptions. >To facilitate adequate alveolar expansion and prevents alveolar collapse. > For early detection and report of respiratory distress and for immediate interventions.

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NCP Proper No. 3 Ineffective breathing pattern


ASSESSMENT O>SPO: 88% > Increased secretions noted. >with episodes of desaturation. >Dry skin noted. >Restlessness. > Tachypnic; RR:24-26 breaths per minute. A> Impaired gas exchange related to ventilation perfusion imbalance. EXPLANATION OF THE PROBLEM Affect on the phrenic nerve that exit at C3-C4 due to cord swelling. OUTCOME CRITERIA STO: After 2 3 hours of nursing intervention, the patient will demonstrate improved ventilation and adequate oxygenation by SPO2. LTO: After 3 days of nursing and medical intervention patient will demonstrate improved ventilation and adequate oxygenation as evidenced by absence of signs and symptoms of respiratory distress. INTERVENTION Dx>Assessed respirations: quality, rate, pattern, depth and breathing effort. RATIONALE > Rapid, shallow breathing and hypoventilation affect gas exchange by affecting carbon dioxide levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and/or apnea are all signs of severe distress that require immediate intervention. >To note for precipitating factors that can lead to impaired gas exchange. >For prompt intervention for the prevention of impending respiratory arrest. EVALUATION STO: Fully met as evidenced by SPO2 of 96 98 %

Impairment of diaphragmatic function

Respiratory muscle strength decreases

LTO: Fully Met. No manifestations of respiratory distress.

Decreased oxygen content of inspired gas Hypoventilation may happen, diffusion abnormality, altered V/Q ratios.

>Assessed lung sounds for any adventitious sounds. >Assessed for any signs and symptoms for impending respiratory distress.

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Decreased pulmonary capillary network, inadequate alveolar ventilation

>Assessed for signs of hypoxemia

>Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia. > Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain. >Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treatment immediately as it is a late development of hypoxia. > To obtain data for comparison for any changes. SPO2 is useful in detecting changes in oxegenation. >Early supplemental oxygen is essential in all trauma patients since early mortality is associated with

IMPAIRED GAS EXCHANGE

>Assessed changes in orientation and behavior.

>Assessed skin color for development of cyanosis, especially circumoral cyanosis.

> Monitored vital signs and SPO2.

Tx>Maintained on supplemental oxygen at 2-3 liters per minute per tpiece.

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>Maintained head of bed on semifowlers position. >Suction every hour and as needed.

inadequate delivery of oxygenated blood to the brain and vital organs. >Promotes better lung expansion and improve gas exchange. >Suctioning aides to remove secretions from the airway and optimizes gas exchange. >Promotes alveolar expansion and prevents alveolar collapse. >To prevent fatigue and decrease oxygen consumption.

Ed> Encouraged to do deep breathing exercises and coughing techniques. >Encouraged to have adequate rest periods

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NCP Proper No. 4 Impaired Physical Mobility Activity Intolerance Impaired Bed Mobility Total Self Care Deficit
ASSESSMENT
Subjective: Patient sometimes refuses log rolling due to pain Objective: History of MVA Spinal Cord Injury(c5-c6) On Halo

PROBLEM EXPLANATION
Motor Vehicular Accident Cervical Spinal Cord Injury Paralysis (Quadriplegia) Impaired physical mobility

OBJECTIVES
STO: (For the 12 hour shift) 1)During the first 1- 2 hours of the shift, the health care professional would gain compliance from the patient in performing nursing interventions

NURSING INTERVENTION
DX Assessed functional level classification

RATIONALE
Baseline data to determine limitations of movement and basis for comparison for effectiveness of interventions Pain alters the ability to participate and

EVALUATION
STO: Partially Met There were times when the patient did not give conformity to log rolling schedules due to pain felt. Interventions were given to relieve the pain. However, the patient still

Assessed for presence of pain

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Vest Inability to move extremities Muscle strength of 0/5 on 4 extremities With log rolling schedule

2) Patient will be log rolled as scheduled and passive range of motion exercises will be performed LTO: The patients watchers will be able to perform passive range of motion exercises and log rolling to the patient

do activities. Assessment can result to better pain management. Observed for non verbal cues of pain Once the presence of pain is identified, appropriate intervention can be given to gain clients compliance in doing other interventions

verbalized that he feels pain so he refused to be log rolled. LTO: Patients watchers verbalized understanding the importance of log rolling and doing passive range of motion

Assessed skin status TX Clustered nursing intervention To prevent skin breakdown and monitor for bed sores To limit fatigue and maximize participation in care Reduce pressure on susceptible areas and risk for abrasions or skin breakdown Passive range of motion

Kept bed dry and free of wrinkles

Performed passive range of motion on all extremities

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Log rolled the patient as scheduled

helps in facilitating circulation and prevents muscle atrophy Adhering to the log rolling scheduled helps facilitate circulation and prevent further skin breakdown Including the patients support system in the plan of care is important. It enables them to participate in the clients health care plan

Demonstrat ed and to the watchers how to perform passive range of motion and log roll

Facilitated hygiene of the patient like shampooing his hair and oral hygiene EDX Emphasized to the watchers the importance of log rolling and doing passive range of motion to the patient

Since the patient is fully dependent, we should facilitate his daily hygiene As a health educator, the nurse teaches the clients support system in simple

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interventions.

NCP Proper No. 5 Impaired Tissue Integrity


ASSESSMENT
pressure sore present on the sacral area, characterized as grade III , about 3 4 inches in diameter, reddish in color, no pus noted , and non odorous pressure sores also

PROBLEM EXPLANATION
Motor Vehicular Accident Cervical Spinal Cord Injury Paralysis (Quadriplegia) Prolonged bed rest Pressure Sores Impaired Tissue

OBJECTIVES

NURSING INTERVENTION
Assess site of skin impairment and determine etiology

RATIONALE
Prior assessment of wound etiology is critical for proper identification of nursing interventions Systematic inspection can identify impending problems early

EVALUATION
STO: Partially Met There were times when the patient did not give conformity to log rolling schedules due to pain felt. Interventions were given to relieve the pain. However, the patient still

STO: (For the 12 hour shift) 1)During the first 1- 2 hours of the shift, the patient will verbalize willingness to participate in nursing interventions

Monitor site of skin impairment at least once a day for color

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noted on the lateral aspect of both lower extremities, anterior aspect of the feet and on the calcaneal area of both lower extremities, characterized as grade II, about 1 2 inches in diameter, no pus noted skin appears dry on halo vest (spinal cord inury)

Integrity

2) Patient will be log rolled as scheduled and passive range of motion exercises will be performed LTO: After 2 months of nursing intervention, the patients bed sore will not worsen as evidenced by: Decrease / Same characteristics of bed sores

changes, redness, swelling, warmth, pain, or other signs of infection Assess client's nutritional status

verbalized that he feels pain so he refused to be log rolled. Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing Massage may lead to deep-tissue trauma LTO: The patients bed sore on the lateral aspect of both lower extremities, anterior aspect of the feet and on the calcaneal area of both lower extremities were marked as grade 1. The pressure sore on the sacral area remained the same characteristics.

Avoid massaging around the bed sore and over bony prominences Provide daily wound care / Apply prescribed ointment

Cleaning the wound daily and applying the ordered ointment prevents impending infections

Transfer
Do not position client on site of skin impairment. If consistent with overall client client with care to protect against the adverse effects of external mechanical forces such as pressure,

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management goals, turn and position client at least every 2 hours Maintain egg mattress in place

friction, and shear

This helps
reduce shear and friction which can also prevent worsening of the present pressure sore and prevent new ones from forming Including the patients support system in the plan of care is important. It enables them to participate in the clients health care plan As a health educator,

Demonstrat ed and to the watchers how to perform passive range of motion and log roll

Emphasized to the watchers the

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importance of log rolling and doing passive range of motion to the patient

the nurse teaches the clients support system in simple intervention s.

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